Extraordinary measures

Daloni Carlisle talks to a physio who’s ahead of the game in terms of measuring levels of patient satisfaction.

You think you’re doing patients good – after all that’s your job and day after day you see them leaving your care with more function and the information they need to help themselves. But could you prove it?

That’s the question now being put to physiotherapists in the new clinical outcome regime. It is not enough to know how many patients you have treated or how long your waiting lists are. In future you will need to show what difference you are making to their lives.

Chris Brookes, team leader of the musculoskeletal outpatient physiotherapy service at Dorset County Hospital NHS Foundation Trust, now has this information to hand. In fact, he has two years worth of data showing how much better patients feel after contact with his service.

The department uses a standard questionnaire with all patients at the start and end of their treatment. Called the EQ5D, it’s internationally recognised, simple to administer and is used across a wide range of conditions in the NHS – such as surgery for hip and knee replacement, varicose veins and hernia repair.

‘It came off the back of CSP guidance on self referral,’ explains Mr Brookes. ‘We were thinking about getting involved and part of the advice was that we would need some baseline data before we started.’

Patients’ views

EQ5D is what is known as a patient reported outcome measure (PROM). It measures patients’ perceptions about their health on the day they fill in the questionnaire. The answers they give to five questions can be summed up into a numerical score (the CSP provides an EQ5D calculator), on a scale of 0-1, with 1 indicating feeling in full health. The difference between the ‘before’ and ‘after’ scores gives a measure of how much the patient has improved.

Mr Brookes’ first task as he introduced a PROM in 2009 was persuading the team of its worth. 

‘We looked at the various outcome tools – and some of them are very lengthy and complex – and decided to go with EQ5D because it is simple, quick, scientifically-supported and can be used for all the patients who use our department,’ he says.

Senior staff trialled it for two months before Mr Brookes took the idea to the team. ‘We outlined what we wanted to do and why we thought it was important to improve our data collection. We explained that we did not know the future of physiotherapy and we needed to future proof ourselves against competition.’

After Mr Brookes had addressed the inevitable questions about working to tight timescales and not wishing to devote time to a questionnaire, the team agreed to try it in the outpatient departments of the trust’s two hospitals.

After four months of data collection, he says, the staff were ‘reasonably happy’ and now EQ5D data collection is routine.

Significant improvement

‘We staple questionnaires to the notes and patients fill them in during appointments,’ says Mr Brookes. ‘The secretaries put the data into Excel spreadsheets so we can calculate the scores.’

He now has data on just over 70 per cent of the 8,000 patients referred to the team every year at his fingertips. ‘There are inevitably a few who attend only once or do not attend their second appointment. There are a few whose first language is not English and those who have left their reading glasses at home,’ he says.

The data show that patient scores rise by an average of 0.2 on the 0-1 scale. ‘It would not be accurate to say that this is a 20 per cent increase,’ Mr Brookes explains. ‘But it is showing that patients feel they have improved significantly.’

As yet, Mr Brookes has not been asked to share the data with commissioners. ‘We are having meetings with commissioners but we are still being asked about process targets and waiting times. But I think it will come and then we will be ahead of the curve.’

Mr Brookes says to others considering using PROMs: ‘It is important to engage staff early and to explain why this is needed. It’s about keeping it simple and achievable for people. It is easy to collect too much data.’

The CSP is keen to see other departments follow suit. ‘I think physios have not always been fantastic at collecting data about their services,’ says CSP professional adviser Steve Tolan. ‘Often frontline staff are not fully engaged and see it as hassle and more paperwork. Sometimes they are asked to collect data and nothing is done with it, leaving them wondering what it was all about.’

But, he adds, they will need to do more in future. ‘All physios - whether in the NHS or independent sector - are going to have to demonstrate their cost effectiveness and the quality of the service.’

Two key aspects that the English government wants commissioners to consider as they look at the NHS services they buy are PROMs and PREMs - patient reported experience measures.

PREMs are, broadly, patient satisfaction, rather than outcome, surveys. Mr Tolan says: ‘Most hospitals will run generic surveys twice a year but in future physios will need to show how satisfied patients are with the service they provide.’

The CSP has supported the use of EQ5D as a useful generic PROM. It also recommends the Consultation and Relational Empathy (CARE) measure, developed by Dr Stewart Mercer and colleagues at the universities of Glasgow and Edinburgh, as a generic PREM. Both are supported by good evidence and are easy to use. The CSP is also looking to develop disease-specific PROMs and is now working with specialist groups on long term conditions, paediatrics and palliative care.

The final piece of the jigsaw is demonstrating the evidence base of services to commissioners. While many physios will be used to thinking about the evidence base, Mr Tolan says fewer will have experience of putting this into terms that are relevant to non-specialists.

‘I think we are going to have to start to develop this as a skill,’ he adds. ‘Commissioners are going to want to see how you comply with NICE guidance, or national or international guidelines. Physios are going to need to develop conversations with commissioners where they can demonstrate this.’

Daloni Carlisle

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